Breathless in India: Are we staring at an allergy epidemic?

Food allergies are rare here, but respiratory allergies triggered by air pollution, sometimes proving fatal, have the nation scratching its head.

Air pollution is a significant contributor to allergic conditions like asthma. In India, 37.9 million people—equal to more than half of the UK’s population—live with asthma.

Carrot and beetroot. This duet of perfectly innocuous vegetables had been as natural a part of Leela’s (name changed) diet as anybody else’s. But one day, at 50, when the Bengaluru-based techie developed lesions along her jaw, her doctor, through a process of elimination, came up with a prognosis: Leela was allergic, not to the two veggies, but to the artificial colouring applied into the roots. And the doctor was right: “My lesions were gone the moment I stopped eating the vegetables,” says Leela.

“Food allergies have grown explosively in the 21st century,” states the latest cover story of the popular science magazine New Scientist. The study points to everything from cow’s milk and shellfish to beer, pollen and egg. This explosive growth in food allergies has also led to a rise in severe allergic reactions requiring hospital admissions.

Hospital admissions for severe allergic reactions, says the New Scientist, have risen dramatically in the US and UK: “The number per 1,00,000 people increased from 153 in 2004 to 218 in 2016. The equivalent figure in the UK grew by more than 179 per cent from 1998 until 2018,” New Scientist’s cover story stated. The allergic reactions include eczema, fever, streaming eyes, vomiting, and diarrhoea.

The cover story, “The end of allergies?”, however, documents a “recent surge of new treatments” to allergic reactions among people, such as the omalizumab jab and other immunoglobulin E (IgE) blockers against possible allergens such as peanuts, and oral immunotherapy (which involves feeding people tiny, but escalating, doses of their trigger allergen).

Suffocating in India 

While food allergies are a major concern, air pollution is another significant contributor to allergic conditions like asthma. Halfway around the globe, in India, 37.9 million people—equal to more than half of the UK’s population—live with asthma. Lancet, in a 2020 paper, noted that “the burden of asthma in India exceeds the number of people with HIV infection or tuberculosis”. It quoted a study that found the prevalence of allergic rhinitis to be a staggering 24.4 per cent in children aged 13–14 years. This high burden of asthma and allergic rhinitis in India is linked to the country’s air pollution levels.

And the cause? India happens to have one of the highest concentrations of air pollution caused by biomass burning, fossil fuels, and vehicular exhaust. “Nearly 77 per cent of the Indian population is exposed to PM2.5 exceeding the limit of 40 μg/m3 set by National Air Quality Standards in India (the limit set by WHO is <10 μg/m3),” says the Lancet paper. While air pollution is a significant contributor to allergic conditions in India, an expert opinion suggests that not all cases of rhinitis may be allergic in nature.

Frontline asked the country’s leading otorhinolaryngologist, Dr Mohan Kameswaran, if allergies are indeed rising in India. “There is a definite increase in rhinitis, for instance, which manifests as a group of symptoms including a cold. But is it always allergic rhinitis? That is not necessarily the case,” says Dr. Kameswaran. “We see both perennial and seasonal rhinitis.” The latter could be associated with pollen allergy, for example.

Boys stand near a fire that broke out at the Ghazipur landfill in New Delhi on April 22, 2024. | Photo Credit: MONEY SHARMA

But there is a clear link, he says, between rhinitis and contemporary living conditions in India: over-crowded residences that affect air quality, the chemicals that surround us. Allergens affect the nasal passage, the first respiratory portal of entry into the body. “The body has a mechanism to protect us. It reacts by closing up the nasal pathways, which swell and produce mucus to wash these chemicals out.”

A study published in 2020 in the World Allergy Organization Journal, however, finds that there has been a “rise in prevalence of allergic rhinitis and asthma” in India. Worryingly, “The Death and Disability Associated Life Years (DALY) per case of asthma in India was 2.4-fold higher than the global average”. This high burden of allergic conditions in India is linked to factors like the use of biomass fuels, and exposure to allergens from houseflies, rice grain dust, and cockroaches. Compounding the issue, treatment of these conditions is often inadequate due to factors like affordability, religious beliefs, myths, and stigma. The annual economic burden of asthma in India is a staggering Rs.71 billion (Rs 7,100 crore) according to the paper.

The good news, however, is that the prevalence of clinically relevant food allergies, especially to peanuts, is “extremely low” in India, unlike in, say, the West. The paper cites studies of allergic reactions to other foods such as chickpeas, citrus fruits, eggplant, milk, and fish. This conclusion is corroborated in a paper published in The Journal of Allergy and Clinical Immunology that finds that food allergy is “extremely uncommon” in India. A clue to this lower prevalence might lie in the early-life exposures to certain food groups in India.

There is, nevertheless, “an urgent need for a strategic multipronged approach to enhance quality of care for allergic disorders,” the World Allergy Organization Journal paper cautions. Several lacunae exist in the diagnosis and treatment of allergies in India, including the lack of India-specific scientific data, lack of aerobiological data regarding pollen and spores, poor asthma management, lack of access to medications, and inconsistent precautionary food allergy labelling. Addressing these gaps is crucial to tackle the growing epidemic of allergic disorders in the country. “There is a need to raise awareness of this growing epidemic, within the medical community and amongst national policy makers and the public at large,” the paper concludes.

That said, even for those who have successfully identified and avoided certain allergens, new allergies can emerge, leading to a continuous struggle. Take Leela for instance. She has a new condition to contend with now: an inscrutable allergy that makes the skin around her eyes painfully dry. “It is going to be another frustrating round of elimination. I have been told to avoid all scented products to start with, before I zero in on the cause.” The challenges faced by the likes of Leela highlight the need for better awareness, diagnosis, and management of allergic conditions in India.

About a toxic relationship.

Pollution has long plagued India’s health, extending beyond urban areas to rural regions. Despite this, policy responses have been inadequate. Here’s a selection of articles from our archives offering insight and critical perspectives on the issue.

• Air pollution in India: A nightmare that continues to haunt
• India in search of clean air
• India’s Air-pocalypse: Understanding the air pollution crisis in Delhi and beyond
• Delhi’s air pollution: Taming a killer
• Visakhapatnam and Hyderabad air most toxic in south India
• Air pollution can affect bone density
• Air pollution in India: A nightmare that continues to haunt

Have pollution-induced allergies affected you? How are you managing? Share your thoughts with us.